REGISTRATION FORM
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Registration Fee = 1,395.00
Fee Includes
o Uniform Package
 Reversible Jersey
 Reversible Shorts
 Shooting Shirt (long sleeve and short sleeve)
 Hoody
 Reversible Backpack
Coaches Fees
Practice Fees
Tournament Fees
AAU with Extended Benefits Coverage; the Membership Card will need to be purchased separately for $16.00
IMPORTANT: All players must be AAU members to participate. Go to www.AAUsports.org to purchase $16
membership. Please bring copy of the AAU Extended Benefits Membership Card to your first practice.
TOTAL: ________________________ (Personal checks payable to: BACKCOURT HOOPS)
Payment due at the first practice play attends following acceptance into the program……
REQUIRED INFORMATION
PLAYER NAME: _____________________________________________________________________________________
BIRTH DATE: (mm.dd.yyyy) _______________________ GRADE: __________ AGE: _____________
PLAYING EXPERIENCE: YMCA: _________ ALODIA: ________ OTHER: _________
ADDRESS: _________________________________________________________________________________________
CITY/ZIP: ______________________________________________ PLAYER CELL PHONE: _________________________
PARENT / GUARDIAN #1 NAME: ____________________________________ CELL PHONE: _______________________
EMAIL #1: _________________________________________________________________________________________
PARENT / GUARDIAN #2 NAME: ____________________________________ CELL PHONE: ________________________
EMAIL #2: _________________________________________________________________________________________
PARENTAL CONSENT FORM
The unsigned, being a parent or legal guardian of the child requesting program admittance, does hereby affirm the applicant is in good health, and suffers from no illness, disability or
condition that requires the taking of medication on a regular basis unless that condition is disclose or approved. Furthermore, the undersigned has no knowledge of any reason the applicant
cannot participate in vigorous physical activity.
The undersigned hereby expressly agrees to be responsible for any medical bills incurred in the treatment of any illness or accident. In the event of any such accident or injury, I hereby
consent to the allowing of BACKCOURT HOOPS program supervision to procure any medical treatment deemed advisable on behalf of my child or ward without prior consent. Neither
BACKCOURT HOOPS, nor other participating BACKCOURT HOPS facilities provide primary medical insurance.
I understand that, as a condition of admittance as a player, the undersigned, on behalf of all parents, and on behalf of the applicant, hereby releases BACKCOURT HOOPS, all participating
BACKCOURT HOOPS facilities, and all other coaches, employees, or agents of the organization from any and all liability from injury or illness, mental or physical, suffered by the player during
or related to the program, unless caused by willful act or gross negligence by the person or entity against whom the claim is made.
I also authorize the use of player photos & videos for all business and marketing purposes regarded appropriate by BACKCOURT HOOPS. I understand posting player photos & videos on the
worldwide web or social media may involve misuse by individuals outside the organization.
This is the ________ day of ___________, 2017.
PARENT / GUARDIAN NAME (Print):_____________________________________________________________________
PARENT SIGNATURE: _________________________________________________________________________________